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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA U4.1 .lj.� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ti1Dx <br /> (Complete in Triplicate) 04 a , <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describ d. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Jab Address 3ZV'r CityG.� �t Size PM <br /> Owner's Name 0/ Phone` <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 6 Dia. of Well Casing <br /> i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> .� .w • . - - <br /> I ] Irrigation -Approx. Depth I 1 Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> WellDestruction ❑ Well Diameter �� Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other , <br /> i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth IN <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal,. <br /> + Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ ' No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth r Size _ Number <br /> SUMPS Ll Distanceto nearest: Well Foundation Property Line , <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this,permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." y•y <br /> The applica st call for all required ' ctions. C pl to drawing on reverse-side:' Q�'7 <br /> Ov <br /> Signed Title: 7�� Date: Z 'P—Jlr9 i7 <br /> FOB DEPARTMENT USE ONLY L4 <br /> Application Accepted by w� .,,. e.,,,n(`� Date Wt "�� Area <br /> Pit or Grout Inspection by Date Final Inspection by, ��� Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO rOUNT DUE AMOUNT REMITTED I CK H RECEIVED 8 DATE PERMIT NO. <br /> + EH 13-24iREV.iiNsl �•�^� +� <br /> EH 14-M � x/"1 7` / <br /> 17 <br /> J 0 Q <br />